Truth gets buried under broken rules

North Carolina medical examiners have issued thousands of rulings about how people died without ever viewing their bodies – one of the most basic requirements in any death investigation.

A state guideline instructs in bold letters that they “must personally view every dead body” in cases they accept. But often they skip the inspection and send the bodies on to funeral homes for burial or to forensic laboratories for autopsies.

Such negligence has major implications for criminal justice and public health. Experts said it would be a firing offense in their states.

“They are doing themselves and the community an injustice,” said Dr. Glenn Wagner, chief medical examiner for San Diego County, Calif., whose office is nationally accredited. “... There are homicides that are masquerading as suicides.”

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N.C. medical examiners ignored the guideline in 11 percent of cases from 2001 through mid-2013, an Observer analysis of state data shows. But because they are essentially volunteers for the job, the state has little authority to hold them accountable.

When 74-year-old Mary Alice Shaver died at her home in Chatham County late one night in 2012, Dr. James Holt did not go to her house. He did not look at her body. After being notified by law enforcement, he simply telephoned Shaver’s husband.

Dan Shaver remembers the conversation:

“He told me, ‘Well, obviously this is heart failure.’

“I said, ‘Everything is heart failure. I want an autopsy.’ He indicated I could have a private autopsy.”

“He knew nothing about her,” Shaver said. “... I wanted an answer and he didn’t have one. I just needed to know what happened.”

Shaver, who grew up in Mecklenburg County, paid Duke University Medical Center $1,750 for an autopsy of her organs that showed – as he suspected – that Mary Alice did not die of heart failure. She died of complications from a hiatal hernia.

System still broken

The state entrusts around 350 local medical examiners with the power to make rulings in sudden, violent, accidental, unattended and suspicious deaths. Those deaths account for about 13 percent of deaths in North Carolina – roughly 10,000 of 75,000 deaths each year.

Medical examiners are usually called in by emergency technicians, police, hospitals or attending physicians.

North Carolina depends mostly on physicians and nurses to do the work on their own time, a practice that dates to the late 1960s when the state vowed to do away with a weak, decades-old system of elected county coroners. The expectation was that professionals with medical training would bring more expertise.

Some doctors who volunteer as medical examiners maintain there is often little to gain, and more to lose, by viewing bodies if no foul play is suspected: They might have to strand patients in their waiting rooms or go out in the middle of the night despite working full-time jobs.

In Rowan County north of Charlotte, medical examiners failed to look at bodies in four of every 10 deaths they investigated. The worst performance came in Chatham County, a historically rural area in the geographic heart of the state, now a popular bedroom community to the Raleigh-Durham area. Medical examiners there did not view bodies in six of every 10 deaths.

There’s little incentive – they are paid $100 for each investigation.

“The big problem with medical examiners is it is a volunteer position, so they can’t be forced ... to do anything,” said Marcia Herman-Giddens, adjunct professor at UNC Gillings School of Global Public Health. Herman-Giddens was a member of a 2001 state study group that recommended sweeping reforms, which the state largely ignored.

“Why would anyone want to do it?” she asked. “The pay is small and the work can be time-consuming.”

Trying to reform

Dr. Deborah Radisch has tried to make changes since taking over as chief medical examiner in 2010, but with limited success. She pointed out in a December 2011 newsletter that not viewing the body “defeats a main purpose of the medical examiner system.”

Some medical examiners are more conscientious than others. In Davie County, near Winston-Salem, medical examiners viewed bodies in all but four of about 330 cases they worked on during more than 12 years.

Investigators in Mecklenburg viewed virtually every body in every case they undertook. But Mecklenburg operates differently than other counties. It led the movement to replace the old coroner system, and now, with $1 million in county money, has four full-time investigators, five part-time investigators and three forensic pathologists trained in the study of violent deaths.

Radisch said there could be legitimate reasons why a medical examiner doesn’t view a body. For instance, if a nursing home or hospital doesn’t report a suspicious death, the body could be buried or cremated before anyone – such as a family member – alerts a medical examiner.

However, if medical examiners routinely fail to view bodies, Radisch said she or another pathologist will contact them. She sent handwritten notes in September 2011 to two Chatham County examiners – Holt and Dr. Michael Tyler – warning that their reappointments were “absolutely contingent” on examining bodies.

Tyler, who failed to view bodies in about 25 percent of his cases, quit in 2012.

One doctor’s rationale

Holt said Radisch’s attempt to enforce state guidelines is reasonable, especially in urban areas where medical examiners do not have the same familiarity with residents as medical examiners in rural communities.

But Holt, who has served as medical examiner for about 30 years, said he is able to skirt some rules because he knows most law enforcement investigators and many of the deceased in Chatham County, which has about 67,000 residents. As a family doctor in the county seat of Pittsboro, he said he is often familiar with a person’s medical history.

If investigators report a suspicious death, Holt said, he will go to the scene and view the body. Otherwise, he said he doesn’t need to.

“I don’t have to go out there and say, ‘Yep, they’re dead.’ ”

Holt did not look at bodies in 75 percent of deaths he investigated from 2001 through mid-2013, data show. That’s 150 of 200 cases referred to him because of unanswered questions about how a person died or because state guidelines required a medical examiner’s review.

Records indicate Holt is known for not viewing bodies and for not being accountable to the state office in Raleigh:

• In a 2009 case, a state pathologist noted: “Dr. Holt did not call or do a(n) external exam.”

• In 2011, a pathologist said: “Dr. Holt released the body from the scene to the funeral home without ever viewing the body.”

• And in 2012, a pathologist used capital letters to express his apparent frustration: “WE HAVE NOT HEARD FROM DR. HOLT AT ALL ON THIS CASE.”

Alarming statistics

John Dykers Jr. also worked as a medical examiner in Chatham County but quit before Radisch wrote the reprimands. He neglected to look at bodies in 73 percent of his cases, nearly as often as Holt.

Dykers, 78, of Siler City, said if he knew he was going to send a body to the state office in Raleigh for autopsy, there was no need for him to see it. “I found out over time, I didn’t really add anything to this,” he said. “So let’s expedite things and get the good eyes on it quicker.”

But experts say the context of where a body is found – including its condition and the circumstances – is part of the investigative trail that must be documented.

State data show that more than half of the cases Dykers investigated were closed without him viewing the body or ordering an autopsy.

Dykers stepped down as medical examiner in 2010 and surrendered his medical license because of what he said were unfounded allegations that he inappropriately discussed sexual matters with a young patient.

Seriously ill

Even after Radisch warned Holt to view the bodies, he neglected to look at them in about half of all the deaths he investigated, including Mary Alice Shaver’s.

Mary Alice fell ill in October 2012 while she and Dan were driving home from visiting a daughter in Florida. She thought it was something she ate. Late the next evening, Oct. 17, she was still so nauseated and her hands so cold that Dan decided to call an ambulance.

No, no, she insisted. I’m fine.

Despite her protests, Dan went to the kitchen to call.

Mary Alice could be stubborn, but Dan was too worried to let her have her way. They met in 1987 while he worked in Charlotte as director of human resources at the Observer and Mary Alice directed the Master’s in Journalism program at UNC Chapel Hill. They had recently returned to North Carolina after 4 1/2 years in Sweden, settling in Fearrington Village between Pittsboro and Chapel Hill.

Dan called 911, then walked back to their bedroom. Mary Alice was unconscious. By the time medics arrived, she was dead.

A death, a phone call

Investigators notified Holt at 11:10 p.m., and Shaver said Holt then telephoned him.

On a death investigation report filed with the state, Holt erroneously wrote that Mary Alice Shaver “fell over dead on the bed while dressing.” She was lying in the bed, Shaver said.

On the report, Holt listed the cause of death as “pending” because of Shaver’s decision to pay for an autopsy.

Holt said in an interview that he assumed she died of natural causes based on what law enforcement told him. He could have requested an autopsy to pinpoint the exact cause, but said it was unlikely the state would take the case.

“A healthy 74-year-old falls over dead in bed. There’s nothing suspicious. After age 65 or so, statistics show the most common cause of death is acute heart failure,” Holt said. “If I had called the medical examiner’s office and asked for an autopsy, I guarantee you they would not have given me permission.”

Regardless, Holt was supposed to examine her body. State regulations require it.

Once a case is complete – in this instance, after the private autopsy – the medical examiner’s office in Raleigh files an amended cause of death in the county where the person died. Weeks passed, and Mary Alice’s death certificate read “pending.” Without an official cause of death, Shaver was unable to claim her life insurance policy.

Shaver said he confronted Holt at his office and again by phone. “I was getting extraordinarily frustrated.”

After three months, Radisch intervened. She wrote Holt and told him to submit a supplemental death certificate to the county. A month later, the change was finally made.

As emotionally wrenching as it was to watch his wife die, then have to take it upon himself to find out why, Shaver believes there’s a bigger issue:

“One hundred dollars is not really a reasonable incentive for a successful doctor to get up in the middle of the night and drive who knows how many miles to visit the scene of the death.”

Viewing the body is critical

In her letter to Holt, Radisch reprimanded him for how he handled the investigation: “You should not release the body for a private autopsy unless you have completed your examination, which includes viewing the body, obtaining toxicology specimens for our office, and certifying the cause and manner of death.”

Radisch said she could not stress enough the need to examine the body in every case he accepts. “This is the critical part of being a medical examiner.”

Dr. Thomas Clark, a former N.C. pathologist who is now chief medical examiner for Washington’s Pierce County, said viewing the body is the only way to find injuries. “There’s no medical justification,” he said, “for not looking at the body.”

Dr. Gregory J. Davis, a former N.C. medical examiner, now a forensic pathologist in Kentucky, was blunt about what he would do: Fire the medical examiner.